Emergency Department Visits by Pediatric Patients for Snakebites.

OBJECTIVES: Few studies have examined pediatric emergency department (ED) visits for snakebites. This study sought to examine characteristics of pediatric patients presenting to EDs nationally in the United States for snakebites. METHODS: This retrospective cohort study obtained data from the Nationwide Emergency Department Sample for 2006 to 2014. Pediatric patients sustaining a snakebite were identified with International Classification of Diseases, Ninth Revision, E-codes E905.0 or E906.2. Data extracted included age, sex, insurance, disposition, hospital trauma designation, ED charges, and geographic region. Comparative analyses were performed for patients younger than 10 years and aged 10 to 17 years. RESULTS: There were 24,388 ED visits from 2006 to 2014 by pediatric patients for snakebites: 10,554 were younger than 10 years, and 13,834 were aged 10 to 17 years. Males comprised 62% and 67% of the respective age cohorts. Most patients (younger than 10 years, 68%; aged 10-17 years, 63%) experienced snakebites in the South. Only 14% of those younger than 10 years and 10% of those aged 10 to 17 years were treated at a level 1 trauma center, whereas 50% and 54%, respectively, were treated at hospitals with no trauma designation. The majority of patients were discharged from the ED (younger than 10 years, 72%; aged 10-17 years, 80%). The mean ED charges for snakebite victims younger than 10 years were $5363 and for those aged 10 to 17 years were $4618. Medicaid was the primary insurer of younger patients, whereas private insurance was more common in older patients. CONCLUSIONS: Most pediatric snakebites are seen in nontrauma centers and in the South region and are more commonly male. Most patients were discharged from the ED, with a small percentage being admitted or transferred to another facility.

Enhancing research for undergraduates through a nanotechnology training program that utilizes analytical and bioanalytical tools.

Nanotechnology is a broad field combining traditional scientific disciplines; however, analytical chemistry plays an important role in material design, synthesis, characterization, and application. This article emphasizes the uniqueness of nanotechnology and the importance of providing high-quality undergraduate research experiences to both attract and retain talented individuals to the field of nanotechnology. In response to this need to develop a strong and sustainable nanotechnology work force, strategies to create authentic research experiences are considered within the framework of an interdisciplinary nanotechnology environment at West Virginia University. The program, named NanoSAFE Research Experiences for Undergraduates (REU), embeds students in different departments at West Virginia University and in research laboratories within the National Institute of Occupational Safety and Health. A large number of participants have little or no prior research experience and a strong effort is made to recruit applicants from under-represented populations. Components designed to foster research proficiency include frequent reporting, a strong peer-network, and training for secondary mentors. Evidence, which includes student publications and assessment findings demonstrating self-efficacy, is discussed to substantiate the viability of the strategies used in the 2016-2018 program. Graphical abstract ᅟ.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

INTRODUCTION: The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS: Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS: Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION: A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

Non-targeted hepatitis C virus screening in acute care healthcare settings in the Southern Appalachian region.

Objectives: The objective of this study was to evaluate the performance of non-targeted hepatitis C virus (HCV) screening in emergency departments (EDs) and other healthcare settings in terms of patients identified with HCV infection and linked to HCV care. Methods: In the Southern Appalachian region of the United States, we developed non-targeted HCV screening and linkage-to-care programs in 10 institutions at different healthcare settings, including EDs, outpatient clinics, and inpatient units. Serum samples were tested for HCV antibodies, and if positive, reflexed to HCV ribonucleic acid (RNA) testing as a confirmatory test for active infection. Patients with positive RNA tests were contacted to link them to HCV care. Results: Between 2017 and 2019, among 195,152 patients screened for HCV infection, 16,529 (8.5%) were positive by antibody testing, 10,139 (5.2% of screened patients and 61.3% of patients positive by antibody test) were positive by RNA testing, and 5778 (3.0% of screened patients and 57.0% of patients positive by RNA test) were successfully linked to HCV care. Among 83,645 patients screened in EDs, 9060 (10.8%) were positive by HCV antibody, and 5243 (6.3%) were positive by RNA test. Among patients positive by RNA testing, linkage to care was lower for patients screened in the ED (44.1%) compared with outpatient clinics (67.6%) (P < 0.01) and inpatient units (50.9%) (P < 0.01). Conclusions: Non-targeted HCV screening in acute care settings can identify large numbers of people with HCV infection. To optimize the utility of these screening programs, future work is needed to develop best practices that consistently link these patients to HCV care.

Evaluating West Virginia's Emergency Medicine Workforce: A Longitudinal Observational Study.

Objective Although the urban emergency workforce is well studied, rural departments are less understood. This study seeks to further define the landscape of rural healthcare and expand on previous studies of the West Virginia (WV) workforce. Methods During the second quarter of 2019, surveys were sent via email to medical directors' professional IDs as anonymous survey links. Hard copies were also sent to directors at their hospital addresses. Responses were aggregated with hospitals stratified based on annual census and rural classification. Data was interpreted through descriptive analysis. Results Surveys were sent to 53 departments with a 55% response rate. Of the responding hospitals, 15 of 29 were identified as rural. The average state-wide annual hospital census was 29,500 visits with board-certified emergency medicine (EM)-trained physicians covering 67% of shifts. Rural departments have a smaller census and less specialized coverage. Full-time physicians are found to have the strongest ties to WV, with 65% attending medical school, residency, or growing up in the state. Conclusion Board-certified EM-trained physicians provide some level of coverage in most emergency departments in WV but remain underrepresented in rural locations. This specialized coverage has increased by 20% in the last 15 years. Additionally, a majority of hospitals have access to basic consulting services (surgery and primary care); however, other specialists are rare in rural WV.

Lessons on Mass Gatherings Learned From the 2019 Union Cycliste Internationale Mountain Bike World Cup.

The Union Cycliste Internationale (UCI) Mountain Bike World Cup in 2019 provided unique challenges for effective prehospital care. While on-site medical care has demonstrated improved outcomes along with reduced emergency department and emergency medical services (EMS) utilization, this aspect has not been well documented in the literature with respect to rural mass gathering events (MGEs). Conducted at a large mass gathering event in a geographically isolated area, this study aimed to assess the medical needs at this specific event and will hopefully assist in future coordination of similar events. All patients who were treated at the event clinic were included in the analysis. Primary investigators collected and recorded data while providing care. We believe the on-site clinic was successful in reducing barriers to healthcare by improving access, streamlining the treatment process, and optimizing resource utilization. This benefit extended to race participants, support staff, spectators, and the local EMS system.

Lower-Third Standardized Letters of Evaluation in Emergency Medicine: Does Gender Make a Difference in Match Outcome?

Objective The purpose of this study was to determine whether gender influences the likelihood of receiving a lower-third global assessment (GA) on the standardized letter of evaluation (SLOE) submitted as part of the emergency medicine (EM) application process as well as the impact of gender on ultimate match outcomes for applicants receiving a lower-third GA ranking. Our hypothesis was that female applicants with a lower-third GA ranking have a higher risk of not matching. Methods We conducted a retrospective cohort study evaluating U.S.-based allopathic applicants to a single EM residency program in the Mid-Atlantic region during the 2017-2018 and 2018-2019 match cycles. GA SLOE rankings and gender for all applicants were extracted and compared to the National Resident Matching Program (NRMP) data for each applicant on match outcome. Comparative analyses were conducted between gender and SLOE GA rankings in order to obtain an odds ratio (OR) of gender and match outcomes. Results A total of 2,017 SLOEs were reviewed from 798 applicants in the 2018 and 2019 EM match cycles. Overall, 716 (90%) applicants successfully matched in EM, with 82 (10%) applicants failing to match into EM; 277 students had at least one lower-third GA ranking. For all applicants, having at least one lower-third GA ranking was associated with a significant risk of not matching (OR: 0.20; 95% CI: 0.12-0.34). Of the 277 students with at least one lower-third GA ranking, 85 (31%) were female and 192 (69%) were male. Of the female applicants with a lower-third GA ranking, 15 (18%) failed to match in EM, and 39 (20%) of the males failed to match in EM. For applicants with a lower-third GA ranking, female gender alone was not associated with a significantly increased risk of not matching (OR: 1.18; 95% CI: 0.61-2.21). Conclusions Female applicants receive a lower-third GA ranking less frequently than their male counterparts. One or more lower-third rankings on the GA significantly reduced an applicant's chances of matching into an EM program. For those with a lower-third GA ranking, female gender alone does not significantly increase the risk of not matching into EM.

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

INTRODUCTION: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. METHODS: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant's likelihood to receive an invitation to interview. RESULTS: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications - 48 total (5.5 %, p< 0.01) - with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). CONCLUSION: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD's focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report.

INTRODUCTION: Dyspnea is commonly evaluated in the emergency department (ED).The differential diagnosis is broad. Due to the large volume of dyspneic patients evaluated, emergency physicians (EP) will encounter uncommon diagnoses. Early, liberal application of point-of-care ultrasound (POCUS) may decrease diagnostic error and improve care for these patients. CASE REPORT: We report a 48-year-old male presenting to the ED with cough and progressively worsening dyspnea for 11 months after multiple healthcare visits. Using POCUS, the EP was immediately able to diagnose a severe dilated cardiomyopathy (DCM) with left ventricular thrombus. CONCLUSION: Given that non-ischemic DCM is one of the most common etiologies of heart failure, often presenting with respiratory symptoms, POCUS is key to rapid diagnosis and, along with modalities such as electrocardiography and chest radiograph, should be standard practice in the workup of dyspnea, regardless of age or comorbidities.

Coexistence of Substance Abuse among Emergency Department Patients Presenting with Suicidal Ideation.

BACKGROUND: Patients who are suicidal commonly seek care in the emergency department (ED). Few studies have examined the coexistence between suicidal ideation, substance abuse, and psychiatric diagnosis. OBJECTIVES: This study sought to determine how often suicidal ED patients have coexisting substance abuse and psychiatric diagnosis in addition to describing the characteristics of target population. METHODS: In this retrospective cohort study, chart reviews were conducted of patients over 12 with suicidal ideation who presented to an academic ED from October 2016 to March 2017. Data abstracted included gender, age, insurance, prior psychiatric diagnoses, substances abused, presence of a suicide attempt, prior suicidality, number of ED visits in the prior year, and disposition. Both descriptive and inferential statistics were calculated. RESULTS: There were 427 patient visits to the ED for suicidality during the study period, of which 54% were male, with a mean age of 34 years. Most patients (92%) had a psychiatric diagnosis, most commonly depression (67%). More than one psychiatric diagnosis was reported in 51% of patients, while 8% had no reported underlying psychiatric diagnosis. Substance abuse was reported in 58% of patients, including marijuana (42%) and opioids (41%). Polysubstance abuse was reported in 42%. Approximately half of the patients had three or more ED visits in the previous 12 months. Most patients were insured by Medicaid (51%), while 59% were admitted for inpatient treatment. CONCLUSION: Substance abuse and psychiatric diagnosis were reported frequently among patients presenting to the ED with suicidal ideation, often involving more than one substance/diagnosis. Future studies should be aimed at evaluating the relationship between these conditions and determining how to better care for this population.

Lower-Third SLOE Rankings Impede, But Do Not Prevent, A Match in Emergency Medicine Residency Training.

OBJECTIVE: Emergency medicine program directors (PD) value the standardized letter of evaluation (SLOE) as the most important aspect of a residency application when making both invitation and ranking decisions. This study aims to determine whether the presence of any lower-third in either SLOE global assessment (GA) question impacted the ability of an applicant to match into EM. We hypothesized that any lower-third ranking would be associated with increased odds of not matching into EM. METHODS: We conducted a retrospective cohort study evaluating allopathic applicants from medical schools in the United States (US allopathic applicants) to a single EM residency program during the 2018/2019 match cycles. GA SLOE rankings from all applications were tabulated and compared to the applicant's National Resident Matching Program (NRMP) match outcome. Comparative analyses were conducted between SLOE groupings and odds ratios (OR) were calculated. RESULTS: A total of 2,017 SLOEs from 781 US allopathic applicants were analyzed during the study period. Of the total, 277 (35%) applicants in our sample had any lower-third GA ranking, which significantly decreased an applicant's odds of matching in EM by 79% (OR 0.21, 95% CI, 0.12-0.34). Having more than one lower-third GA ranking did not further statistically decrease the odds of a successful EM match (OR 0.60, 95% CI 0.31-1.17). As a secondary finding of the study, results demonstrate that those applicants having no lower-third GA rankings had a nearly 5 times increased odds of an EM match (OR 4.84, 95% CI, 2.91-8.03). CONCLUSION: Having any lower-third GA ranking significantly reduced an applicant's chances of matching into an EM program. Faculty advisors should be aware of the increased risk of not matching for any applicant with any lower-third GA ranking and advise students appropriately, while maintaining the integrity of the SLOE and not divulging the confidential information contained within.

Student Integration into STEM Careers and Culture: A Longitudinal Examination of Summer Faculty Mentors and Project Ownership.

It is widely recognized that the United States needs to attract and retain more people in science, technology, engineering, and mathematics (STEM) careers. Intensive undergraduate research experiences (UREs) are one of the few strategies shown to improve longitudinal student interest and persistence in STEM-related career pathways; however, less is known about the underlying process linking activities to positive outcomes. The tripartite integration model of social influences (TIMSI) provides a framework for understanding the social influence processes by which students integrate into STEM careers and culture. The current study used a longitudinal design and latent growth curve modeling to examine and predict the development of scientific research career persistence intentions over the course of an intensive summer URE. The latent growth curve analysis showed that student persistence intentions declined and rebounded over the course of the summer. Furthermore, the positive impact of faculty mentor role modeling on growth trajectories was mediated through internalization of science community values. In addition, project ownership was found to buffer students from the typical trend of declining and rebounding persistence intentions. The TIMSI framework illuminates the contextual features and underlying psychological processes that link UREs to student integration into STEM careers and culture.